Sometimes (when making changes in healthcare), less is more.

Exnovation may be a valuable tool in the improvement science toolbox, so why isn’t it used more? In the following article I explore what barriers inhibit it’s use and potential enablers to support its application.

This week we hosted a webinar by Maureen Bisognano (President Emerita and Senior Fellow, Institute for Healthcare Improvement) and Dr Mark Jarrett (Chief Quality Officer at Northwell Health, New York) focusing on leadership and resilience in a crisis. During the workshop, Maureen spoke about the important role ‘exnovation’ can have during a crisis, and more broadly to support improvements in care services. This is an issue Maureen has been emphasising for some time. I first heard Maureen speaking about exnovation at the 2015 BMJ & IHI International Forum in London. In her talk, Maureen presented a few simple questions; ‘How do we stop what doesn’t work anymore?’ and ‘How will we eliminate wasteful practices and processes?’ Maureen also spoke about the need for courage to engage in exnovation. The issue of reducing or removing is always important, but a recent article in Nature by Professor Gabrielle Adams and colleagues explores the issue from a scientific perspective and helps further our understanding of why exnovation may be such a challenge in healthcare.

The article, titled: ‘People systematically overlook subtractive changes’ (2021) shows that people systematically default to searching for additive transformations (adding stuff), and consequently overlook subtractive transformations (eliminate stuff). Across eight experiments, the article describes how participants were less likely to identify advantageous subtractive changes when: 1. The task did not cue them to consider subtraction, 2. When they had only one opportunity to recognize the shortcomings of an additive search strategy or 3. When they were under a higher cognitive load. In summary, the authors suggest that defaulting to searches for additive changes may be implicated in a variety of costly modern trends, including overburdened minds and schedules, increasing bureaucracy and even humanity’s damaging impact on the planet. If people default to additive transformations—without considering comparable (and sometimes superior) subtractive alternatives—they may be missing opportunities to make their lives more fulfilling, their institutions more effective and their planet more liveable.

One of the co-authors of the paper – Leidy Klotz has a book that takes a deeper look at the topic, 'Subtract: The Untapped Science of Less'.

“In our striving to improve our lives, our work, and our society, we overwhelmingly add. In each of these situations, we’re all doing essentially the same thing—trying to change things from how they are to how we want them to be. And in this ubiquitous act of change, one option is always to add to what exists, be it objects, ideas, or social systems. Another option is to subtract from what is already there.”

Klotz explains that his ‘eureka’ moment came whilst playing Lego with his son. Together they had built a structure with two columns and a connecting bridge. Unfortunately, the two columns differed in height, so the structure was wonky. Klotz chose to look for another brick to add to his column to ensure it was equal in height, whilst his son (3yr old) simply took a brick away from his column. Simple, elegant, and efficient.

• A summary of his book and a short video summarising this moment are available here: https://behavioralscientist.org/subtract-why-getting-to-less-can-mean-thinking-more/

How is this relevant to improving health care? The appeal by Maureen Bisognano for people to think about exnovating is based on lessons learnt from within healthcare, such as the ‘Getting Rid of Stupid stuff’ campaign (Ashton, 2018) which focused on reducing the administrative burden on clinical staff to ensure they increase the time they spend with patients, or the story of Christian Farman, who had learned how to give himself dialysis — with the support of nursing staff at Ryhov County Hospital hemodialysis clinic in J?nk?ping, Sweden. Closer to home, we can think of the Sikkert Patient Flow program which focuses amongst other things, on reducing waiting times. A successful example from which involves day surgery patients going directly to the operation room themselves, instead of engaging in the traditional steps of being admitted with the need of a bed and being transported to the operation room.

These examples are atypical. Often when we work with health care services, and ask them to understand their systems and processes, to identify where the challenges may be (and thus where the opportunities for change may be), the change ideas identified as potential improvements typically constitute adding something to the process, such as a new checklist or collecting more data. Of course, both of these may be appropriate interventions. However, I rarely experience people suggesting a subtraction as a change idea. Which is curious, because ‘The Improvement Guide’ (Langley et al., 2009) which for many people constitutes the primary text to guide their improvement work, has a number of ‘subtractions’ included in the section on ‘Change Concepts’ (p364 – 408). Indeed, the section starts with: ‘Eliminate Things That Are Not Used’, 2. ‘Eliminate Multiple Entry’, 3. Reduce or Eliminate Overkill’, 4. ‘Reduce Controls on the System’.

ALL of which are subtraction interventions!

The question for me is therefore, ‘Why do people typically identify an additive change idea and not a subtractive one?’ Again, the paper by Adams and colleagues, provides an explanation:

“Across many domains of judgment, people rely on quick and easy mental shortcuts—especially when high cognitive demands preclude the pursuit of more tailored approaches and in the absence of information that cues alternative strategies. Thus, if additive search is a common default, people should be more likely to rely on it when they are cognitively loaded and—conversely— they should be less likely to rely on it when task experience or task information cues them to use another strategy.”

The mental shortcuts that the authors refer to are ‘heuristics’ or ‘cognitive biases’ which are numerous and powerful (cf. Kahneman, 2011, Thinking, fast and slow). Heuristics are cognitive shortcuts that allow us to react or respond quickly to the world but can often lead us to the wrong decision. The issue of cognitive load is explored in ‘Scarcity: Why Having Too Little Means So Much (Sendhil Mullainathan & Eldar Shafir, 2013) but can be summarised as the cognitive resources (mental bandwidth) available to engage fully with thoughts, memory, decisions, etc. When our ‘bandwidth’ is full, we tend to make inferior decisions. In increasingly busy work settings, this leads to an inevitable downward spiral. Finally, the issue of ‘cues’ relates to the contextual guidance or reminders which can support (or hinder) decisions. This subject is explored in detail by Richard Thaler and Cass Sunstein in their book ‘Nudge: improving decisions about health, wealth, and happiness (2009)’ which looks at the role and philosophy of ‘choice architecture’.

Put into context, improvement work can be described as the systematic application of methods and tools aimed at reducing variation and increasing the quality and safety of the care provided. Even after 30 years of application (2021 is the 30th anniversary of the IHI) and a wealth of guidance, the research literature indicates that there is a “continued need for improvement in quality improvement methodology” (Knudsen, et al., 2019). Perhaps one area for improvement could be to emphasise subtraction as an idea worth exploring more rigorously and systematically. This would include being aware of issues relating to cognitive capacity to support clear thinking and salient reminders (nudges or choice architecture) that subtraction is an option.

I would also like to reflect on Maureen’s point that exnovation needs courage. This feels instinctively accurate and speaks to the need to understand the role of culture, and more specifically feeling empowered and psychologically safe to engage in exnovation. These issues have garnered a great deal of interest in the organisational psychology literature (cf. Khan et al., 2020), but limited attention from the field of improvement science (Nembhard & Edmondson, 2006). This may also be a potential area that improvement science could explore more thoroughly.

Of course, there may well be a need to add something in order to improve it, it seems our brains and our cultures are ‘hard-wired’ to add more. However, with a greater appreciation of courage, cognitive capacity, and reminders in our healthcare improvement work, we may well have access to a greater diversity of solutions, more or less.

References:

Adams, G.S., Converse, B.A., Hales, A.H. et al. People systematically overlook subtractive changes. Nature 592, 258–261 (2021). https://doi.org/10.1038/s41586-021-03380-y

Klotz, L (2021) Subtract: The Untapped Science of Less. Flatiron Books

Ashton, M. (2018) “Getting Rid of Stupid Stuff.” New England Journal of Medicine, vol. 379, no. 19, pp. 1789–1791., https://www.nejm.org/doi/full/10.1056/NEJMp1809698

A Patient Directs His Own Care. https://www.ihi.org/resources/Pages/ImprovementStories/APatientDirectsHisOwnCareFarmanSelfDialysis.aspx

Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP (2009). The Improvement Guide. A Practical Approach to Enhancing Organizational Performance (2nd Edition) San Francisco, California, USA: Jossey-Bass Publishers.

Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus and Giroux.

Mullainathan, S., & Shafir, E. (2013). Scarcity: Why having too little means so much. Times Books/Henry Holt and Co.

Thaler, R & Sunstein, C. (2009) ‘Nudge: improving decisions about health, wealth, and happiness. Penguin ISBN: 9780141040011

Knudsen, S.V., Laursen, H.V.B., Johnsen, S.P. et al. (2019) Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Serv Res 19, 683. https://doi.org/10.1186/s12913-019-4482-6

Khan, J., Jaafar, M., Javed, B., Mubarak, N. and Saudagar, T. (2020), "Does inclusive leadership affect project success? The mediating role of perceived psychological empowerment and psychological safety", International Journal of Managing Projects in Business, Vol. 13 No. 5, pp. 1077- 1096. https://doi.org/10.1108/IJMPB-10-2019-0267

Nembhard, I.M. & Edmondson, A.C. (2006) Make It Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safe and Improvement Efforts in Health Care Teams. Journal of Organization Behavior, 27, 941-966. https://dx.doi.org/10.1002/job.413